3 research outputs found

    Delivery of clinical preventive services in family medicine offices.

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    BACKGROUND: This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODS: We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTS: Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns. CONCLUSIONS: Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices\u27 propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations

    Understanding Organizational Designs of Primary Care Practices.

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    During the past decade, many hospitals experienced difficulty integrating primary care practices into their health systems. We hypothesized that this difficulty may be, in part, a result of limited understanding of practice organizational designs. The structure and function of practices have not been well studied. In this article, we answer the following questions: Are practices all the same, or do variations in their organizational design exist? Do hospital designs predict the designs of affiliated practices? If variation exists, what are the management implications? Eighteen family practices, including nine affiliated with five separate hospital systems, were studied using an in-depth comparative case study design. A content analysis of the rich descriptive data from these cases indicates that a great variety exists in the organizational design of primary care practices, and this variety appears to be influenced by the initial conditions under which the practice was organized. Hospital system design in and of itself did not predict the design of affiliated practices. In fact, both affiliated and independent practices exhibited a range of design characteristics, some of which did not fit traditional models. Hospital systems that allowed greater flexibility of practice organizational designs were more effective at integrating and managing practices. Practices response to environmental change was greater when practice autonomy was highest. These findings suggest that a science of practice organizational design separate from that of hospitals is needed to help explain the success and failure of practices within health systems and to provide information for planning practice change

    Primary care practice organization and preventive services delivery: a qualitative analysis.

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    BACKGROUND: Rapid developments within the health care environment have led to increased pressures for change among primary care physicians and their practices. Nevertheless, a lack of understanding of practice organization and function has limited the effectiveness of attempts to change practice behaviors. Recent attempts to increase the delivery of preventive health care services illustrate the limitations of current approaches. To assist physicians in their attempts at change, our study looked at the office as a whole system and at the competing demands within the primary care setting. METHODS: Qualitative fieldnotes were recorded by research nurses who observed 138 family physicians in 84 practices in northeast Ohio for 4 days each. These data were content-analyzed to identify features that are important for understanding how practices are organized. RESULTS: These data indicate that primary care practice is much more complex than research and transformation efforts generally acknowledge. The data identified a diverse set of features that describe how primary care practices are organized and function. These included cognitive and behavioral components of physician philosophy and style, and numerous features of the practice organization, such as office efficiency, clarity of staff roles, communication patterns among physicians and staff, and approaches to using office protocols. The data also suggest that some practices are more innovative than others and that some physicians or staff have special motivations that can support or inhibit a particular change. CONCLUSIONS: Physicians who want to change their practice, as well as those persons who want to stimulate change from the outside, need to have a more comprehensive approach than is now commonly used to assess practices that encompass a broad spectrum of variables